Major Depressive Disorder Case Study

Case Background:
The condition of severe and persistent treatment resistant Major Depressive Disorder prompted treatment with S-Adenosyl Methionine, which resulted in new and unusual tactile and visual hallucinations which the patient described as being of mice and snakes crawling on their body.

Major Depressive Disorder is mental disorder characterized by at least two weeks of low mood present across most situations and is often accompanied by a feeling of being down, depressed, or hopeless, as well as low self-esteem and disturbance in activities of daily living as well as sleep and appetite.

Tactile hallucinations are the false perception of tactile sensory input that creates a sensation of physical contact with an imagined object. Tactile hallucinations can be due to drug or alcohol consumption or may be independent of

treatment interventions.

A visual hallucination is a “perception of an external visual stimulus where none exists” (Pelak, 2014)

Intervention Background:
SAM-e is a natural substrate found in the human brain, believed to function as a methyl donor in several physiological processes (CANMAT 2016). SAM-e is often prescribed in Europe at doses of 800-1600mg/day in divided doses, for Major Depressive Disorder (CANMAT 2016).

Generally SAM-e is well tolerated, with the most common side effects being insomnia, sweating, headache, irritability, restlessness, anxiety, tachycardia, and fatigue (De Berardis D, 2016).

SAM-e has a potential interaction with medications that prevent the reuptake of serotonin including SNRI medications such as Desvenlafaxine, but the likelihood of development of serotonin syndrome due to the interaction is rare and generally SAM-e will only potentiate the therapeutic effects of a serotonin-effecting medication and is therefore often used as a second line adjunctive therapy alongside antidepressant medications (CANMAT 2016).

Reports of mania due to activation exist in the literature but reports of psychotic symptoms due to SAM-e are not in existence to date (NCCIH, 2017).

Pharmacological antidepressant medications however, have been noted to trigger hallucinations in patients and a 2009 case report describes a 44 year old patient who experienced visual hallucinations with the initiation of 75mg of Venlafaxine (Tripp, 2009).

Case Presentation
SC is a 49 year old Romanian female who presented to the Robert Schad Naturopathic Clinic in October 2017 with Severe treatment resistant Major Depressive Disorder and a history of Obsessive Compulsive preoccupation with suicidal intent.

She had been treated for severe treatment resistant MDD with 22 rounds of Electroconvulsive therapy and upwards of 10 different psychopharmacological interventions since 2002. She had been hospitalized on two occasions for suicidal intent, and only responded positively to fluoxetine, however discontinued due to digestive upset. After two weeks of starting therapy with SAMe, SC began to make marked improvements in her depression, as evidenced by self-reported scores on the PHQ-9 as well as self and her husband’s reports. After approximately 4 weeks on SAMe, SC discontinued it’s use due to the beginning of the experience of tactile and visual hallucinations. SC had begun treatment with Desvenlafaxine in June 2017, which could also be attributed to the symptoms, but given that the hallucinations only began five months into treatment, it is less likely that this was the sole contributor to those

symptoms.

Subjective Information and Relevant Medical History:
SC had a history of hospitalization and treatment for suicidality, and had been prescribed many different psychopharmacological treatments since 2002. SC went through approximately 20 sessions of electroconvulsive therapy with some improvement in frequency and severity of suicidal thoughts. Sorina was taking 100mg of Desvenlafaxine when she first sought treatment at RSNC, and began a treatment of 400mg of SAMe in October, and moved up to 800 mg of SAMe after 5 days weeks later. After approximately 2 weeks on treatment with SAMe, Sorina’s scores on the Patient Health Questionnaire (PHQ-9) had began to improve, but she reported to begin having tactile and auditory hallucinations, which she described as seeing and feeling snakes and mice crawling on her body. Although her symptoms of depression had improved, she found this